By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (Lenalidomide) Covered by Blue Cross Blue Shield in Virginia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Revlimid Covered by Blue Cross Blue Shield in Virginia

Blue Cross Blue Shield of Virginia requires prior authorization for Revlimid (lenalidomide), with approval depending on FDA-approved indications like multiple myeloma, documented prior treatment failures, and enrollment in the mandatory Lenalidomide REMS program. Your oncologist must submit clinical documentation showing medical necessity, typically including failure of at least two prior therapies and specialist prescriber credentials.

Fastest path to approval:

  1. Verify your prescriber and pharmacy are REMS-certified
  2. Have your oncologist submit prior authorization via the BCBS provider portal with complete treatment history
  3. If denied, file internal appeal within 180 days, then external review with Virginia's Bureau of Insurance within 120 days

Start today: Contact your oncologist to confirm REMS enrollment status and begin gathering documentation of prior therapies and treatment failures.

Table of Contents

Coverage Basics

Is Revlimid Covered by Blue Cross Blue Shield in Virginia?

Blue Cross Blue Shield of Virginia (primarily Anthem Blue Cross Blue Shield) covers Revlimid (lenalidomide) for FDA-approved indications, but prior authorization is mandatory. As of 2025, many BCBS plans are transitioning to prefer generic lenalidomide over brand-name Revlimid, which may require additional medical necessity documentation for brand coverage.

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all lenalidomide products PA form, clinical notes, treatment history BCBS VA Provider Portal
REMS Enrollment Mandatory FDA safety program Patient, prescriber, pharmacy certification FDA REMS Requirements
Prescriber Qualification Oncologist or hematologist only Specialist credentials and signature BCBS Clinical Criteria
Line of Therapy Typically requires 2+ prior treatment failures Timeline with dates, doses, progression evidence BCBS PA Guidelines
Formulary Status Varies by plan; generic preferred Check plan formulary or member portal BCBS Formulary

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify REMS Status (Patient/Prescriber)
    • Confirm enrollment at the Lenalidomide REMS portal
    • Timeline: 1-3 business days if not already enrolled
    • Required for: Patient pregnancy testing/contraception counseling, prescriber certification, pharmacy authorization
  2. Gather Clinical Documentation (Oncologist)
    • Complete treatment history with dates, doses, and outcomes
    • Pathology reports confirming diagnosis (multiple myeloma, MDS, etc.)
    • Lab results showing disease progression or treatment failure
    • Timeline: Same day if records are organized
  3. Submit Prior Authorization (Oncologist/Office Staff)
    • Use BCBS provider portal or fax PA form
    • Include ICD-10 diagnosis codes (e.g., C90.00 for multiple myeloma)
    • Attach medical necessity letter and supporting documents
    • Timeline: Submit within 24-48 hours of prescription
  4. Track Application Status (Patient/Office)
    • Monitor via provider portal or call BCBS pharmacy services
    • Standard review: 10-14 business days
    • Expedited review: 72 hours for urgent cases
    • Timeline: Check status after 5 business days
  5. Coordinate Specialty Pharmacy (Patient)
    • Transfer prescription to BCBS-approved specialty pharmacy
    • Provide REMS confirmation number
    • Schedule delivery once PA is approved
    • Timeline: 2-5 days for first shipment

Timing and Deadlines

How Long Does Prior Authorization Take?

  • Standard Review: 10-14 business days from complete submission
  • Expedited Review: 72 hours for urgent medical situations
  • REMS Enrollment: 1-3 business days if starting from scratch
  • Specialty Pharmacy Transfer: 2-5 business days after PA approval

When to Request Expedited Review

Request expedited processing if:

  • Current treatment is failing rapidly
  • Delay would seriously jeopardize health
  • Patient is hospitalized or in active treatment
  • Oncologist certifies medical urgency in writing

Medical Necessity Criteria

What BCBS Looks for in Approval

FDA-Approved Indications:

  • Multiple myeloma (with dexamethasone or as maintenance after auto-HSCT)
  • Myelodysplastic syndromes with deletion 5q
  • Relapsed/refractory mantle cell lymphoma
  • Follicular lymphoma and marginal zone lymphoma (with rituximab)

Required Documentation:

  • Confirmed diagnosis with pathology/cytogenetics
  • Prior treatment history showing failure or intolerance of at least 2 regimens
  • Current disease status with recent labs/imaging
  • Treatment plan including dosing and monitoring schedule
  • Contraindications to alternative therapies

Clinician Corner: Medical Necessity Letter Checklist

For Prescribers: Your medical necessity letter should include:Patient's specific diagnosis with ICD-10 codeDetailed prior treatment timeline with specific drugs, doses, duration, and reasons for discontinuationCurrent disease status with objective measures (M-protein levels, bone marrow biopsy results, etc.)Clinical rationale for lenalidomide based on NCCN guidelines or FDA labelingPlanned dosing regimen and monitoring scheduleWhy alternative treatments are inappropriate or contraindicated

Cost Considerations

Understanding Your Coverage

Typical Cost Structure:

  • Specialty tier copayment (often $100-500+ per month)
  • Or coinsurance (20-40% of drug cost)
  • Annual out-of-pocket maximums apply

Manufacturer Support:

  • Bristol Myers Squibb Access Support program
  • Copay assistance for eligible commercial insurance patients
  • Patient assistance programs for uninsured/underinsured
Note: Copay assistance eligibility varies by insurance type. Medicare and Medicaid patients typically cannot use manufacturer copay cards.

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
REMS Non-Compliance Complete enrollment for all parties REMS confirmation numbers
Insufficient Prior Therapy Document specific treatments tried Detailed treatment timeline with outcomes
Non-Specialist Prescriber Transfer to oncologist/hematologist Board certification credentials
Missing Clinical Information Submit complete medical records Labs, imaging, pathology reports
Step Therapy Not Met Request exception with contraindications Medical reasons why alternatives won't work

Appeals Playbook for BCBS Virginia

Level 1: Internal Appeal

  • Timeline: Must file within 180 days of denial
  • Process: Submit written appeal with additional clinical evidence
  • Decision: 30 days for standard, 72 hours for expedited
  • Submit via: BCBS member portal or appeals department fax

Level 2: External Review (Virginia-Specific)

  • When: After internal appeal denial or if BCBS doesn't follow proper procedures
  • Timeline: Must file within 120 days of final internal denial
  • Process: Submit Form 216-A to Virginia Bureau of Insurance
  • Decision: 45 days for standard, 72 hours for expedited
  • Cost: Free to patients

Specialty Pharmacy Requirements

Why Your Prescription Was Transferred

BCBS requires specialty medications like Revlimid to be dispensed through their designated specialty pharmacy network. This ensures:

  • Proper handling of temperature-sensitive medications
  • REMS compliance verification
  • Coordination with prior authorization
  • Patient education and support services

Common BCBS Specialty Pharmacies:

  • Walgreens Specialty Pharmacy: 1-866-515-1355
  • CVS Specialty: 1-800-237-2767
  • Accredo (Express Scripts): 1-833-721-1619

Transfer Process

  1. Verify Network Pharmacy: Call BCBS member services to confirm approved options
  2. Coordinate Transfer: Your prescriber sends new prescription to specialty pharmacy
  3. Provide REMS Info: Share confirmation numbers and enrollment status
  4. Schedule Delivery: Most specialty pharmacies offer overnight shipping

Virginia External Review Process

If your internal appeal is denied, Virginia's external review process provides an independent second opinion. This is particularly valuable for expensive specialty drugs like Revlimid.

How Virginia External Review Works

Eligibility Requirements:

  • Must be a Virginia-regulated insurance plan (not self-funded employer plans unless they opt in)
  • Must have completed internal appeals process
  • Must file within 120 days of final denial
  • Denial must be based on medical necessity, experimental treatment, or similar clinical judgment

Filing Process:

  1. Download Form 216-A from the Virginia State Corporation Commission website
  2. Gather Documents: Final denial letter, medical records, prescriber's letter
  3. Submit to Bureau of Insurance: Mail or fax complete package
  4. Independent Review: Bureau assigns case to qualified Independent Review Organization (IRO)
  5. Decision: IRO issues binding decision within 45 days (72 hours for expedited)

Contact Information: Virginia Bureau of Insurance P.O. Box 1157 Richmond, VA 23218 Phone: 1-877-310-6560

Virginia Advantage: The state's external review process has helped many patients access necessary treatments. The IRO's decision is binding on your insurance company, meaning they must provide coverage if the review finds in your favor.

Troubleshooting Common Issues

Portal Problems

  • Provider Portal Down: Submit via fax with delivery confirmation
  • Missing Forms: Contact BCBS provider services for current PA forms
  • Login Issues: Use "forgot password" or call technical support

Communication Gaps

  • No Response from BCBS: Follow up after 5 business days; document all calls
  • Missing Medical Records: Request copies from all prior treatment centers
  • REMS Delays: Contact manufacturer customer service for enrollment assistance

Pharmacy Issues

  • Prescription Rejected: Verify PA approval status and REMS compliance
  • Wrong Specialty Pharmacy: Confirm network status before transfer
  • Delivery Delays: Track shipments and have backup supply plans

FAQ

Q: How long does BCBS prior authorization take for Revlimid in Virginia? A: Standard review takes 10-14 business days. Expedited review for urgent cases takes 72 hours. REMS enrollment (if needed) adds 1-3 business days.

Q: What if Revlimid is non-formulary on my BCBS plan? A: Request a formulary exception by documenting medical necessity and why formulary alternatives are inappropriate. Include clinical evidence and prescriber justification.

Q: Can I request an expedited appeal in Virginia? A: Yes, both internal appeals and external reviews can be expedited if your doctor certifies that delay would seriously jeopardize your health or ability to regain function.

Q: Does step therapy apply if I failed treatments outside Virginia? A: Yes, treatment history from any location counts toward step therapy requirements. Provide complete documentation of all prior therapies regardless of where they occurred.

Q: What's the difference between generic lenalidomide and brand Revlimid? A: Generic lenalidomide contains the same active ingredient and has the same effects. BCBS typically prefers generic, but brand may be covered with medical necessity documentation showing generic intolerance.

Q: How much does Revlimid cost with BCBS coverage? A: Costs vary by plan but typically involve specialty tier copayments ($100-500+ monthly) or coinsurance (20-40% of drug cost). Manufacturer copay assistance may be available for commercial plans.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and creates evidence-backed appeals tailored to each payer's specific requirements, helping patients access the medications they need.

When navigating complex prior authorization requirements for specialty medications like Revlimid, having expert support can make the difference between approval and denial. Counterforce Health's comprehensive approach ensures that appeals include the right clinical evidence, meet procedural requirements, and address the specific concerns raised in denial letters.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies and procedures change frequently. Always verify current requirements with your specific BCBS plan and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, contact the Virginia Bureau of Insurance Consumer Services at 1-877-310-6560.

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